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The healthcare insurers & bureaucrats positively put the U.S. Army to shame for inventing acronyms and confusing terms. Below are most of the common ones explained in a very simplified form. For a more complete listing, go to http://www.healthinsurance.org P.C.P. - Primary Care Physician - A "Gatekeeper" you select from the network upon enrollment, who generally provides your routine medical care & decides if and when you need to see a specialist. H.M.O., IPA MODEL - Health Maintenance Organization - Closed plan where you can only use listed medical providers, typically with access to specialists controlled by your "PCP" (Primary Care Physician). No insurance outside the plan. "IPA" means Independent Physician Association. HMO, STAFF MODEL - Kaiser type HMO plan where physicians are salaried & work in the plan facility. P.P.O. - Preferred Provider Organization - A plan incorporating both a network of medical providers and an option to go outside it, but at a reduced level of benefits. Members usually may see any doctor in the plan without referral. P.O.S. - Point of Service - A plan incorporating a closed (HMO) network combined with an out-of-network option. Some POS plans utilize three separate levels of benefits: HMO, PPO, and out-of-network. INDEMNITY OR FEE FOR SERVICE - Total freedom of choice in medical providers. This is what we longingly look back on. It is virtually unavailable in the current marketplace, except perhaps to those who could probably pay their own claims anyway. COBRA - Consolidated Omnibus Budget Reconciliation Act - The federal regs governing eligibility & rights to continuation of coverage for employees & dependents when group insurance terminates. HIPAA - Health Insurance Portability & Accountability Act - Federal regs governing eligibility for the purchase of insurance to replace lost group medical insurance. CAL-COBRA - California state regulations applying the federal regs & revisions COINSURANCE - Percentage (usually) the carrier pays of your medical bill, although some may confuse the issue by also using it to mean what you pay. (Cute, huh?) COPAY - Dollar amount you pay for a particular treatment. LIMITED FEE SCHEDULE - The dreaded scale carriers use to dictate payment for each individual medical service when you use medical providers outside their network. The amounts are generally set at whatever level the insurance company wants them to be, which regularly produces payments at some pitifully small percentage of the actual cost. U.C.R. - Usual, Customary, Reasonable -- another scale setting rates of payment for individual medical services, purported to utilize actual historical pricing data. This scale is generally considered better than Limited Fee Schedule, but not much. MEDICARE SCHEDULE - The Medicare scale setting rates of payment for services, generally considered in the same category as Limited Fee Schedule. (or worse) H.I.I.A. SCHEDULE - Another payment scale purported to have been produced by a trade association. |